Hypochondria and medical correspondence at the limits of intersubjectivity

As we have seen, George Cheyne specialized in treating a group of nervous disorders then generally recognized as a single condition, but known by many names. Physicians generally called it either the hypochondriacal affection if the sufferer was a man, or the hysterical affection if the sufferer was a woman.Footnote ⁴ As both labels suggest, the two conditions were understood to arise when the organs beneath the diaphragm – such as the spleen, stomach and womb – interfered with the workings of the more noble organs higher up, including the brain. As a result, many people simply referred to hypochondria and hysteria as ‘the spleen’.Footnote ⁵ Moreover, they identified the condition with a wide array of symptoms linking the lower body to the brain and mind. A sharp pain in the stomach, for instance, might be symptomatic of the same underlying defect responsible for one of the condition's more obviously psychological manifestations, which included inexplicable sadness, obsession and even hallucination.Footnote ⁶ It is well known, moreover, that doctors and their patients tended to see hypochondria as a disease of the wealthy, citing lack of exercise, rich food and drink, and the pursuit of mental rather than physical labour as its causes. Cheyne thus asserted that recent increases in Britain's wealth had led to an epidemic of nervous disorders, writing that ‘the Wealth and Abundance … the Inactivity and sedentary Occupations of the better Sort … have brought forth a Class and Set of Distempers, with atrocious and frightful Symptoms, scarce known to our Ancestors’. Specializing in nervous disorders, Cheyne set himself up as a doctor to people of money and leisure, settling in the fashionable resort town of Bath and attracting many wealthy patients.Footnote ⁷

Like many medics of the eighteenth century, Cheyne established his expertise by publishing books advancing philosophical explanations for the causes and cures of disease. In the English Malady of 1733, Cheyne therefore argued that nervous disorders arose when the body became incapable of efficiently transmitting nutritive fluids such as the blood through its many passages and pores. This difficulty had in turn three causes: an excessive thickness in the fluids; the presence of saline or sulphurous particles in the nutritive fluids which damaged the vessels through which they travelled; and a loss of elasticity in the muscular coatings around the arteries, veins and nerves, ultimately making the nervous system less capable of governing the body.Footnote ⁸ Cheyne sought to give this account intellectual and cultural credibility by framing it in the terms of Newtonian natural philosophy. To take just one example, he argued that saline particles passing through the blood harmed the nervous system because they were governed by a strong attractive force. Separated by the digestive system, those salts would inevitably recombine because of their mutual attraction, forming sharp-edged concretions that would damage the soft and springy fibres of the body, impairing their capacity to regulate its nervous functions.Footnote ⁹ It was for this ostensible reason that Cheyne laid so much stress on dietary restraint as the most durable and effective cure for hypochondria. The way to prevent the passage of these damaging salts into the blood was by avoiding the rich foods and strong liquors that contained them in excessive quantities.Footnote ¹⁰

To this display of propositional knowledge, however, Cheyne added elements gesturing towards an intersubjective model of expertise. The third part of the English Malady is made up of case histories and correspondence from patients intended to illustrate the multiform symptoms of hypochondria, as well as the success of Cheyne's methods. Crucially, the last and longest of those examples was Cheyne's own case history, running to thirty-nine pages. As Anita Guerrini has explained, Cheyne included this case history to demonstrate both his sympathy for his hypochondriac patients, and his intimate acquaintance with their symptoms. She has shown, moreover, that Cheyne framed his own case as a kind of spiritual autobiography, linking the ups and downs of his hypochondria with his wavering capacity to resist the temptations of food and drink. Ultimately, Cheyne claimed to have cured himself through a Christian habit of self-denial, cultivating the durable pleasures of the spirit rather than the ephemeral pleasures of the body.Footnote ¹¹ But he did not present himself as someone to whom this spirit of denial came easily. Instead, he sought community with his fellow sufferers by being open about his moral failures, along with the alarming bodily symptoms to which those failures led. Consider how he reported on his state in the summer of 1723:

Here, Cheyne supplemented the philosophical parts of the English Malady with a detailed and frank account of his own experiences, both moral and physical.Footnote ¹²

In his correspondence with patients, Cheyne placed even more emphasis on the intersubjective parts of his expertise, almost ignoring his philosophical knowledge. In his medical letters to the famous novelist Samuel Richardson (bap. 1689–d. 1761), he made only one or two references to his theories, and none at all in his letters to Hastings. Rather, as Steven Shapin has shown, Cheyne devoted most of his effort to the conjoint tasks of persuading his patients that he cared about their suffering, and of giving them enough courage to persist in the unappetizing diets that he invariably prescribed as the most effective cure for their suffering.Footnote ¹³ Moreover, as both Shapin and Wayne Wild have pointed out, Cheyne used the suggestion that he had suffered in almost exactly the same manner as his patients to further both of these moral–therapeutic objectives. He established his sympathy by claiming to have once felt exactly the same pain and despair as his patients, and he used his intimate experience of the long road to good health as evidence that they could obtain relief by following the same strict dietary regime. In other words, the medical expertise that Cheyne articulated when communicating with his patients depended in large measure on the suggestion that he had once felt the very same symptoms under which they suffered.Footnote ¹⁴ We need to ask, therefore, how Cheyne could make this assertion of embodied intersubjectivity – of having felt the same sensations as his patients. The notion is perhaps plausible in the case of Richardson, who shared Cheyne's sex, corpulent body type and middle-class social situation, and wasn't much younger. Even here, however, the evidence suggests that Richardson was frequently unconvinced by Cheyne's assertions. And what about Hastings? As we have already seen, Hastings was an aristocrat, a young woman and pregnant for much of the time that she corresponded with Cheyne. How could Cheyne persuade her that he had once felt her suffering? And would it ever have been possible for her to accept her doctor's unlikely suggestion?

The obstacles confronting Cheyne were considerable. For one thing, he had to somehow bridge the gap between his own experiences and those of his patients. For another, he had to find ways of communicating about a condition that was notoriously resistant to verbal expression, both because of its multiform symptoms, and because sufferers seemed to experience it in an irreducibly subjective fashion. Consider how the poet Anne Finch (1661–1720) presented hypochondria in her Pindaric ode on ‘The Spleen’, first published in 1701:

These opening lines allowed Finch to display her poetic skill by going on to vividly depict a malady that conventional wisdom saw as impossible to represent.Footnote ¹⁵ But physicians of the early eighteenth century bought into the suggestion that hypochondria could not be adequately described using conventional medical language. The physician and antiquary William Stukeley (1687–1765) thus included Finch's poem in his Of the Spleen, Its Description and History, Uses and Diseases (1711), stating that he had done so in order to ‘to help out [his] own description of the disease’.Footnote ¹⁶ Meanwhile, Sabine Arnaud has shown that the French physician Pierre Hunauld (1664–1728) made similar claims in his Dissertation sur les vapeurs, published posthumously in 1756. There, Hunauld used a fictive dialogue between a physician and two aristocratic women to proffer a diffuse portrait of hypochondria, both in the hope of reaching a non-specialist audience, and because he felt there was no other way to capture the condition's irreducibly subjective and otherwise incommunicable symptoms. Like Stukeley, he sometimes deferred to poetic authority, for instance invoking a description by the ancient Greek poet Sappho (c.630–c.570 BCE) in his attempts to depict the condition.Footnote ¹⁷

As well as specializing in a condition thought difficult to describe, Cheyne often treated young women – people whose bodily experiences may have differed considerably from his own.Footnote ¹⁸ Making this point, I do not mean to suggest that the differences between the sexes were or are fixed, or that embodied intersubjectivity between men and women was or is impossible. On the contrary, scholars including Thomas Laqueur and Barbara Duden have shown that the broadly humoral understanding of the body still prevalent in the first half of the eighteenth century made some fluidity between the sexes possible.Footnote ¹⁹ It is widely known, moreover, that physicians and their patients saw hypochondria as a condition that arose in bodies with feminine characteristics – even when those bodies belonged to men.Footnote ²⁰ Stukeley argued that women were more likely than men to suffer from hypochondria because the solid parts of their bodies – the passages through which the juices flowed – were rendered weaker by a tendency to engage in less physical exertion than men. And in the same text, he suggested that wealthy men were developing similarly lax solids because of their growing tendency to enjoy sedentary forms of life. Stukeley asserted, moreover, that the physical similarity between hypochondriac men and women ran very deep, pointing out that some men endowed with lax constitutions menstruated on a regular basis, whether through the anus or through another orifice.Footnote ²¹

It would be mistaken, however, to suggest that such theories of sexual fluidity enabled early modern people to entirely overlook differences in the bodily experiences of men and women. Wendy Churchill has shown that physicians were nevertheless sensitive to the physical differences between the sexes, often using different treatments to take into account pregnancy and other states of body that seemed unique to women. In addition, some medics and their patients saw hypochondria as a different condition when it occurred in women, being more likely to identify a malfunctioning womb as the cause of the problem.Footnote ²² While Cheyne could therefore call on some theoretical resources to close the gap between his body and that of Hastings, it was by no means obvious that he could speak authoritatively about what she had felt and experienced.

Perhaps the most direct evidence of the challenge confronting Cheyne is to be found, however, in a series of three letters written to Hastings in the first part of 1738 by the aristocrat and political organizer Susan Keck.Footnote ²³ I happened upon these letters at the Huntington Library in California, and although they have been catalogued I do not believe that they have ever come to the notice of historians. Keck was then in her early thirties, and she wrote to Hastings for advice about the treatment she was then receiving from Cheyne for a severe bout of hypochondria. Each of the three letters is between eight hundred and a thousand words long, and, apart from the briefest of pleasantries, they consist of nothing but medical matters, whether lengthy descriptions of symptoms or appeals for advice. Importantly, the letters also reveal that Cheyne's efforts to enter into Keck's feelings were not very successful. She told Hastings about symptoms that she was too ashamed to reveal to Cheyne, and she called his sympathy into question. Perhaps more importantly, she identified Hastings as an alternative source of medical expertise, asserting that Hastings's experiences were so similar to her own that only she could dispense reliable advice.

It would be tempting, therefore, to argue that Cheyne had failed, and that Keck simply sought out someone whose body and experiences were more like her own. But a closer inspection suggests something different. We shall see that Keck was not as confident in the similarity between herself and Hastings as she suggested. In fact, she used some of the very same rhetorical gambits as Cheyne in her efforts to convince Hastings that they had truly undergone the same forms of suffering. Comparing the exchanges between Cheyne and Hastings with those between Keck and Hastings may therefore reveal more similarities than might be expected. There were some important differences in the strategies Cheyne and Keck used to convince Hastings that they could enter into her suffering. But they also seem to have been thinking in broadly similar terms, assuming that only a person who had felt the same symptoms could offer reliable advice about how to end the pains of hypochondria.

Cheyne and Hastings: the experience of erysipelas

George Cheyne's association with the Hastings family started in the 1720s, when he began to treat Lady Elizabeth Hastings (1682–1739) and several other female members of the family. Known to her friends as Betty, Elizabeth served as head of the Hastings family during the minority of her brother Theophilus, 9th Earl of Huntingdon. It was she who negotiated the marriage between Theophilus and Selina in 1728. Cheyne's place in the family's affections depended not only on his medical advice, but also on their shared interest in a form of Christian mysticism – based in part on the writings of French female ascetics such as Antoinette Bourignon (1616–1680) – that would go on to play an important role in the foundation of Methodism. Although Cheyne never joined the movement himself, his ideas about the links between diet and spiritual health met with the approval of leading Methodist personalities such as George Whitefield (1714–1770) and John Wesley (1703–1791). Indeed, it is fairly well known that the medico-religious advice on diet and regimen proffered by Wesley in his Primitive Physick (1747) owed much to Cheyne's earlier prescriptions for an abstemious way of life that would enable those who stuck with it to become healthy in both body and spirit.Footnote ²⁴ In 1739, Selina Hastings and her husband underwent a conversion of their own, and their turn to spiritual religion brought them into a deeper relationship with Cheyne, especially following a visit they both paid him in 1741.Footnote ²⁵ After the deaths of both Cheyne and her husband in the 1740s, Hastings went on to become an important figure in the Methodist movement, in 1783 founding a group of churches known as the Countess of Huntingdon's Connexion, which still exists to this day.Footnote ²⁶

In June 1732, however, when the surviving sequence of letters from Cheyne to Hastings began, the doctor had yet to win her confidence.Footnote ²⁷ Around or just before this time, Hastings conceived a son who would be born around February 1733. She must have let Cheyne know about the pregnancy pretty quickly, since he alluded to it in a letter of 19 July 1732. In these early letters, Cheyne had two main medical objectives. First of all, he proposed a plain diet along with remedies such as spa water, purges and vomits to address Hastings's hypochondria and the underlying digestive difficulties that seemed to arise from that condition. Second, he prescribed various pain-relieving remedies for the unspecified but very painful rash that affected her anus or vagina. Pursuing both these objectives, Cheyne made changes to take Hastings's pregnancy into account. He warned Hastings off reducing her diet to the level he would normally prescribe to a hypochondriac patient, writing that ‘now you have two to feed’. At the same time, he held back from prescribing the more powerful medicines that he would otherwise use to bring about a permanent cure for her rash, hinting that the risks to her and her child were too great to make the attempt worthwhile.Footnote ²⁸ Cheyne's therapeutic approach thus bears out Churchill's argument that physicians took pregnancy into account in the treatments they recommended for their patients, distinguishing between the bodies of pregnant women and those of other people.

During the pregnancy, Cheyne made no effort to suggest that Hastings's symptoms were similar to his own, or to those experienced by anybody else. For the first nine months of the correspondence, he sought only to make Hastings believe that he was truly and ardently determined to help bring about her cure. Indeed, he frequently told Hastings that he took great pleasure from hearing about her symptoms, writing, ‘I shall take a great deal of pleasure as well as receive a great deal of honour in corresponding with you, and if there be truth or love of virtue among men I can assure you of my fidelity, zeal, and sincerity.’Footnote ²⁹ But after Hastings gave birth in February 1733, Cheyne began to change both his medical approach and his affective posture. On hearing of the birth, he immediately sent Hastings a prescription to pass on to her local doctor, detailing a preparation of mercurial medicines to deal with her rash. Soon, he also began telling Hastings about patients who had suffered from similar symptoms and conquered them by courageously sticking to his controversial regimen. In a letter of September 1733, he thus reported on a patient – without identifying either their age or sex – who had laboured ‘under much the same, or rather much worse, circumstances, but longer under the same method and medicines, and is almost perfectly recovered’.Footnote ³⁰ In the next letter, of November 1733, he informed Hastings that she had three neighbours – all of them men – who had suffered from similar complaints and resolved them by sticking to the same diet of milk, seeds and the occasional bit of poultry.Footnote ³¹ We can only guess why Cheyne started encouraging Hastings to learn from the experiences of others at this moment. It may be that he felt Hastings's spirits were flagging, and that she needed encouragement. But we might also speculate that the end of her pregnancy made it possible, at least in Cheyne's mind, to compare her experiences to those of other sufferers, including men.

But Hastings apparently continued to express doubts about the diet she had been prescribed, and Cheyne's next move was to introduce his own experiences. In a letter of February 1734, he reported to Hastings that he had experienced the very same rash that continued to trouble her in her anus or vagina. His words are worth reporting in full:

Here, Cheyne did three things. First, he defined Hastings's rash as an erysipelas, a skin condition otherwise known as St Anthony's fire, and today understood to be caused by a bacterial infection. Cheyne regarded erysipelas as a symptom of hypochondria, and in his English Malady, as we have already seen, he identified it as one of the things from which he had suffered.Footnote ³³ In other words, Cheyne linked Hastings's rash to her hypochondria, while at the same time turning it into a symptom that he had many times felt in his own body. Second, he used his own experience to make Hastings accept that she could only get rid of the pain by sticking rigidly to her diet, pointing out that he had suffered a relapse by allowing himself a few too many rich vegetables. Third, he used this own relapse to build up fellow feeling with his patient, reminding Hastings that he knew well how hard it was to stick to the strict diet upon which her cure depended.

Cheyne had to depart from any conventional account of erysipelas to make it fit with the symptoms that Hastings was actually experiencing. Put simply, erysipelas was (and remains) a skin condition, and you wouldn't expect to find it in the moist flesh of the anus or vagina.Footnote ³⁴ As we have already seen, Cheyne had written about a year earlier to Hastings's local physician with a prescription intended to clear up the rash. In that communication, he admitted that it would be strange to find an erysipelas in the vagina or anus, and as a result he expressed far less certainty about his diagnosis. Again, we need to examine Cheyne's words in full:

Recall that Cheyne adopted a tone of total certainty when he diagnosed the rash for Hastings, explaining that he ‘took it always to be erisipelatous’. Communicating with a fellow physician, by contrast, he was far more circumspect. He acknowledged that the rash was in the wrong place, and therefore qualified it as ‘almost of the erysipelatous kind’.

Writing to Hastings, Cheyne thus concealed what was in fact an uncertain diagnosis. It is striking, moreover, that he referred to the condition by its technical name, derived from Greek. Writing to patients, Cheyne very rarely deployed the jargon of his profession, adopting instead an informal tone consistent with his sympathetic and solicitous persona.Footnote ³⁶ In a letter of 1741, for instance, he tried to persuade Samuel Richardson that the two of them had also suffered from the same symptoms. But here he felt no need for the erysipelas label, instead settling on the more familiar ‘Saint Anthony's Fire’ to account for the skin rashes he had once regularly suffered.Footnote ³⁷ Cheyne therefore worked hard to dispel any doubts Hastings may have had, using a confident tone and a little bit of medical jargon to assert his mastery over the matter at hand. For a moment, you might say, he marshalled the signs of his propositional knowledge to force acquiescence from his patient. But the purpose of this move was not simply to make Hastings acknowledge the diagnosis as true. Rather, it was to bridge the differences between their bodies, and in turn to make her accept that she was suffering from the same symptoms he had once endured, and into which he occasionally relapsed. Cheyne mobilized his epistemic authority in the service of fellow feeling, ultimately suggesting that his expertise depended on having felt Hastings's torments for himself.

To borrow a phrase coined by Steven Shapin in his influential discussion of the science of wine tasting during the second half of the twentieth century, Cheyne's letters functioned as an ‘intersubjectivity engine’.Footnote ³⁸ Their purpose was to produce consensus about constantly changing feelings or experiences that cannot be separated from the operations of perception. It is perhaps this condition that explains why Cheyne felt the need to mobilize medical jargon in his efforts to persuade Hastings that he knew her suffering. On this point, I would suggest that Cheyne had something in common with others who have addressed the difficulties of obtaining consensus about supposedly subjective experiences, whether in the domain of art criticism or in the many practices associated with the tastes of food and drink. Consider, for instance, Ardeta Gjikola's recent study of the debate that took place in Britain about the aesthetic value of the Parthenon marbles following their acquisition by Thomas Bruce, 7th Earl of Elgin (1766–1841). There, she points out that advocates for the marbles managed to convince the public that they were beautiful through the dissemination and repetition of terms used to describe them by supposedly authoritative judges of art. Among artists and connoisseurs, those terms had highly specific meanings referring to both the content of artworks and the experience of beholding them. But when circulated in the wider public, those terms became clichés that had little referential content. She thus reports on the value that the journalist H.E. Lloyd attached to the sculptor Antonio Canova's (1757–1822) declaration that the marbles contained nothing but ‘truth, true, true truth’. Once they had become clichés, the value of such words was not what they communicated about the aesthetic experience provoked by the sculptures. Rather, their value came from showing that people thought to be authoritative judges of art identified them as beautiful. In turn, the dissemination of those clichés in books and periodicals authorized members of the public to share this experience.Footnote ³⁹

The diagnosis of erysipelas functioned in a similar manner. It served to persuade Hastings that Cheyne was an authoritative judge of the sensations she had felt in her own body, and therefore that Cheyne was competent to claim that he had felt the same thing. That does not mean, however, that Cheyne actually succeeded. In later letters, he felt the need to remind Hastings that he had intimate experience of her suffering. In September 1735, for instance, he repeated the series of moves he had made in the previous year. In that letter, he once more deployed medical language to explain Hastings's continued symptoms, ascribing them to ‘sharp scorbutic humor’ working its way out of her body. But this explanation once again served to authorize Cheyne's intersubjective expertise – he immediately followed it with the assertion, ‘All you describe I have felt and gone through, even almost to distraction’.Footnote ⁴⁰ Meanwhile, Cheyne packed his letters to Richardson with similar assertions that he had felt everything the sensitive novelist was going through. He thus wrote in January 1742 that he knew Richardson's condition from intimate personal experience; in May 1742 that he had ‘felt the Grief, Anguish, and Anxiety such a Distemper must have on a Mind of any Degree of Sensibility, and of so fine and lively an Imagination as yours’; and in July 1742 that he had ‘suffered in my own Bacon to a higher Degree than I ever read or heard of in any other Person.’Footnote ⁴¹ In short, he felt the need to frequently remind Hastings and Richardson that his expertise came from an intimate experience of their suffering. The tone of those letters suggests, moreover, that he wrote in part to assuage their doubts about his advice, encouraging them to stick to their prescriptions despite a lack of improvement in their symptoms.

Hastings and Keck: finding another expert

For Hastings and Richardson, we only have access to Cheyne's side of the correspondence, meaning that we have to infer their doubts from his replies. The letters of 1738 from Susan Keck to Hastings, by contrast, are unusual in containing direct testimony from a patient who found Cheyne's advice dubious, and sought a second opinion. Today, Keck is remembered as a political organizer, and historians have written nothing about her health problems. She played a significant role in the Oxfordshire election campaign of 1754, earning the appellation ‘my Lord Sue’ from opponents who sought to depict her political activity as a transgression of gender norms.Footnote ⁴² As far as I can tell, the letters she wrote to Hastings in 1738 are the only evidence that Keck sought out Cheyne's help for hypochondria. However, she had a reputation for being excessively solicitous about her health. In letters written during the first half of the 1740s, both Frances Seymour, Duchess of Somerset (1699–1754) and Horace Walpole (1717–97) commented unkindly on Keck's tendency to spend time in conversation with physicians, and trying out new treatments.Footnote ⁴³

Keck wrote the letters because she knew Hastings was also one of Cheyne's patients. Since Cheyne frequently put his patients in touch with each other, it is possible that he engineered the exchange.Footnote ⁴⁴ From the first of Keck's letters, moreover, we can tell that Hastings encouraged Keck to have faith in Cheyne and his methods: ‘I am Perfectly convinced, and still more Thoroughly confirm'd by Y^r Ladyships opinion, that Doctor Cheyne both from his Judgment Practice, and Probity, is the only person folks in my Distemper can expect the smalest relief from.’Footnote ⁴⁵ But these words of self-reassurance are undermined by the many occasions on which Keck expressed doubt about Cheyne's understanding of her condition, his capacity for sympathy and his methods. In the same letter, for instance, she expressed surprise that her symptoms were just as bad under her prescribed diet as they had been when she ate whatever she wanted. And in June 1738 she began to speak of Cheyne and his regimen – a low diet accompanied by camomile tea and much self-induced vomiting – with resentment:

As well as coming to resent Cheyne's treatments, Keck also began to suspect that Cheyne was insufficiently sympathetic to the suffering she endured on his advice. She thus finished the same letter by writing that Cheyne ‘suspects any body to be gluttous; and never beleves they starve too much, as at least I do’. As the months wore on, therefore, Keck began to question whether Cheyne understood how to treat her condition, and began to suspect him of bullying her into following a regimen that did not produce results.Footnote ⁴⁷

Perhaps the strongest indication, however, that Cheyne did not succeed in building up fellow feeling with Keck comes from her admission that she could not share every detail of her symptoms with him. Cheyne had the same difficulty with Hastings, and it boiled down to the codes of modesty that governed communication between women and men. On several occasions, he gently chastised Hastings for telling him so little about the rash in her anus or vagina that he did not know it was still troubling her.Footnote ⁴⁸ In April 1738, Keck told Hastings that she was too ashamed to tell Cheyne about some things she was experiencing:

Keck felt able to tell Hastings that she sometimes found undissolved Scots pills – a proprietary medicine made up mainly of aloes – in her faeces, but she could not tell Cheyne. Although she did not explicitly state that the issue here was the performance of gender roles, Keck's intimation that she feared Cheyne's contempt strongly suggests that this was the case. She worried that she could not share something so intimate and potentially disgusting with a man – but she did not have the same difficulty when communicating with a woman. The expectation that women should be modest in their conversation with men therefore made it hard for Keck to enter into the community of feeling that Cheyne worked so hard to engender.Footnote ⁴⁹

Although Keck had her doubts about Cheyne, she did not reject the intersubjective model of expertise that he articulated in his books and letters. Instead, she used the very same model to identify another expert, better equipped to understand her symptoms. That expert was Hastings. In each of the surviving letters, Keck told Hastings that she valued her advice beyond that of any other person because the two of them had suffered in exactly the same manner. In each case, moreover, she linked the need for intersubjective expertise to the impossibility of turning the felt experience of hypochondria into a verbal description. Consider what she told Hastings in April 1738, echoing very similar remarks in the preceding letter of March:

In June, Keck made the same point by likening Hastings to a fellow Freemason – somebody who had gained membership of a select group by going through a series of secret trials that would only ever be known to those who had endured them.Footnote ⁵¹ She thus bought into the then-widespread belief that it was very hard to give verbal expression to the symptoms of hypochondria, almost calling medicine by correspondence into question entirely. In consequence, she also bought into Cheyne's assertion that intersubjectivity was the crucial condition for possessing expertise in the diagnosis and treatment of the condition. It was precisely because she shared Cheyne's belief that expertise in her condition could only be obtained through an intimate experience of the same thing that she made Hastings into her doctor – an idea to which she gestured explicitly in the same letter.Footnote ⁵²

Keck therefore grasped and accepted the intersubjective model of expertise that Cheyne used to win over his patients. In addition, she was keenly aware that the difficulty of communicating about the highly subjective and changeable feelings caused by hypochondria made this expertise extremely precarious. Keck knew that it would be difficult to identify with verbal descriptions of her symptoms, and – as she explained – she therefore wrote about them at great length, hoping to make it more likely that Hastings would encounter something that she recognized. In her constant reminders to Hastings that the two of them had experienced identical suffering, moreover, there are shades of the same insecurity so readily apparent in Cheyne's letters to his patients. Why did Keck feel the need to remind Hastings of their shared suffering in each of the letters she wrote? Did she worry that Hastings might not feel the same way? We cannot know the answers to these questions for sure. But we can say that her assertions of similarity echo the ones made by Cheyne in his correspondence with Hastings and Richardson. Unable to put intersubjective experience into words, Cheyne and Keck could only assert that their feelings were like those of other people. Moreover, they had to repeat those assertions over and over again, applying constant emotional pressure in the hope of winning, and then renewing, the precarious acquiescence of their correspondents.

Both Cheyne and Keck seem to have understood, therefore, that the experience of hypochondria was resistant to objectification – that it could not be rendered as a stable series of signs referring to stable object separate from the person perceiving it. Perhaps surprisingly, a comparison to the world of wine tasting may once again help us to understand the model of expertise that Cheyne and Keck premised on the unstable alignment of their experiences. In an article of 2012, Geneviève Teil has explored the debate in France about whether terroir really exists. As Teil points out, terroir is a flavour identifiable in some wines, supposedly indicative of the soil and wine-making practices typical of a given region. Oenological scientists tend to consider that terroir is nothing more than a discursive construct since the gustatory and olfactory qualities used to identify it do not correspond to a stable property to be found either in the wine or in the soil. But Teil rejects this analysis, arguing that it is mistaken to dismiss terroir simply because it cannot be said to exist independently of the collective experiences and judgements through which it is brought into being. Based on the constant evaluation and re-evaluation of wines that themselves differ from year to year, terroir exists not as an object in itself but rather as the constantly emerging, and constantly renewed, product of collective sensory experiences.Footnote ⁵³

There is a lesson here, I think, for interpreting the intersubjective form of expertise that Cheyne modelled in his letters to patients, and with which Keck in some sense agreed. It might be tempting to dismiss Cheyne as a quack or a charlatan if we base our evaluation of his expertise on the extent to which it depended on knowledge of stable objects that exist when they are not being experienced – whether propositional knowledge about hypochondria or knowledge about how to treat that condition. But such an analysis misses the mark. Cheyne and Keck identified expertise with the experience of symptoms that simply cannot be separated from the perceiving subject. As a result, they both struggled with the difficulty of rendering those changeable symptoms in the static form of written words. Their endless and at times implausible invocations of similarity, sometimes lacking in referential content, reflect the constantly changing and therefore precarious task of aligning one person's feelings with those of another.

Taste and intersubjective expertise

At one level, the story of Cheyne, Hastings and Keck is one about hypochondria in the eighteenth century, a topic of perennial interest for historians of literature and medicine. As we have seen, Sabine Arnaud shows that numerous physicians of the eighteenth century used intersubjective modes of writing, including autobiography and dialogue, to gain the trust of their patients when confronted by the peculiarly subjective feelings provoked by the condition. She and others have also demonstrated that this model of medical expertise was closely related to the literary culture of sensibility – the middle-class and aristocratic discourse that dwelt on the role of embodied feelings in shaping the relationships between people, especially men and women.Footnote ⁵⁴ That connection is, of course, eloquently expressed in the friendship between Cheyne and Richardson. Richardson was, after all, perhaps the single most influential figure in the literary canon of sensibility in Britain.Footnote ⁵⁵ Cheyne was thus by no means unique in trying to build fellow feeling with his patients – intersubjective forms of expertise were widely deployed by physicians of the eighteenth century. However, the fact that Keck felt able to apply the same model of expertise to somebody with neither formal medical qualifications nor technical expertise may help us to understand why that intersubjective model of expertise went into decline during the eighteenth century. As Wayne Wild has noted, physicians working later in the century, such as William Cullen (1710–1790), did not make any such effort to establish intersubjective community with their patients. By modelling fellow feeling as the source of his expertise, Cheyne ran the risk of abolishing his authority, enabling his patients to replace him with anybody else to whom they felt a closer or more obvious intersubjective connection.Footnote ⁵⁶

Moreover, Cheyne's intersubjective model of expertise may hold insights relevant not only for historians of eighteenth-century culture and medicine, but also for those with broader interests in the history and sociology of knowledge. For one thing, the decline of embodied intersubjectivity as a form of medical expertise was emphatically not matched by a similar decline in other domains of eighteenth-century thought. As the century wore on, philosophers grew preoccupied by the possibility that finding a consensus of feeling might be the only way to guarantee social harmony. The most famous instances of this preoccupation are Jean-Jacques Rousseau's (1712–78) suggestion that individuals feel an instinctive pitié for those who suffer, and David Hume's suggestion that many of our moral judgements arise from sympathy – from the feelings of pleasure and pain elicited by the reproduction of another person's affective state in our own minds. In his Treatise of Human Nature (1739–4), Hume thus proposed that the irrational form of consensus arising from mutual sympathy was the force giving rise to the moral distinctions that made society between humans possible – not some rational process by which those distinctions might be figured out and delivered as propositional statements.Footnote ⁵⁷

In addition, the intersubjective model of expertise has parallels with the aesthetic theory and art criticism of the eighteenth century. There, thinkers ranging from Francis Hutcheson (1694–1746) to Immanuel Kant (1724–1804) tried to explain how and why consensus about the feelings arising from certain forms of experience was possible. Like Cheyne and his patients, they tried to figure out how individuals might sometimes agree about the kinds of experience that seem to resist assimilation to the kinds of rational calculation from which we derive scientific certainty. Of course, these aesthetic theories sought in some sense to make claims about objects that exist independently of our experiences of them – in the sense that they sometimes sought to define some objects as beautiful and others as un-beautiful. But they worked towards this goal by attempting to work out the conditions under which individuals could obtain consensus about their affective states – about states that simply cannot be separated from our apparently subjective experiences of objects.Footnote ⁵⁸ Elsewhere, I have tentatively suggested that at least some of the theorists of art and aesthetics at work in the first half of the eighteenth century derived ideas about the experience of art from precisely the kinds of medical ideas and practices discussed here. Thus the art theorist and portrait painter Jonathan Richardson (1667–1745), to take just one example, clearly modelled his approach to the judgement of aesthetic value on the dietetic medicine then prescribed for sufferers of hypochondria.Footnote ⁵⁹

More important for our purposes, however, is the task of defining the kind of expertise that has formed the subject of our discussion – and here I think the discourses and practices concerned with taste hold valuable clues. The resemblance to the intersubjective formation of consensus about taste judgements is what has led me to avoid applying the overused term ‘knowledge’ to the form of expertise that Cheyne purported to have, and that Keck identified in Hastings. The term ‘knowledge’ usually refers either to statements about objects that can be said to exist beyond the operations of perception, or to possessing the ability to perform some kind of task.Footnote ⁶⁰ It is true, of course, that Cheyne used knowledge in both these senses to position himself as an expert, especially in printed books. In his letters, however, Cheyne used his knowledge of hypochondria to advance claims about how he and other people experienced the condition. He modelled a form of expertise concerned not with knowledge of hypochondria or how to treat it, but rather with the feelings provoked in him by the condition, and the possibility of aligning those feelings with the ones felt by others. In this form of expertise, Cheyne and his correspondents did not insist on the possibility of thinking about hypochondria as an object that might exist beyond their perceptions of it. Instead, they sought a kind of consensus about hypochondria understood as an experiential event, inseparable from the mechanisms of sensation and perception.Footnote ⁶¹

We have found, moreover, that Cheyne used language in a manner comparable to other people who, at other times and places, have claimed to be experts in matters of taste. Terms such as chiaroscuro and ‘ideal beauty’ have specific and important meanings for artists and art critics, while terms such as ‘tannins’ and terroir have similar functions in the world of wine. When more widely diffused, however, such language often loses its referential content, serving to boost the authority of the person using it rather than as an effective medium for communicating about the experiences for which it stands.Footnote ⁶² Cheyne used the jargon of his discipline in this fashion. Diagnosing Hastings with erysipelas, he didn't just want to persuade her that he understood the cause of her suffering, and could therefore give her the right treatment. Rather, he wanted to convince her that the two of them had felt the same way – despite the obvious differences between their bodies, and despite the fact that he didn't say much about what that experience was like.Footnote ⁶³ Keck's case was different in the sense that she did not suggest that Hastings had either access to special knowledge of hypochondria, or expertise in its treatment. In the final evaluation, however, she depended on Cheyne's logic when turning Hastings into her doctor. Like Cheyne, she wanted to persuade Hastings that the two of them had felt the same way.

The model of medical expertise shared by Cheyne, Hastings and Keck does not conform, therefore, to our expectations of a form of expertise based on knowledge – at least knowledge as it is conventionally understood. It was not the knowledge of hysteria understood as an object of inquiry, and neither was it the knowledge of how to treat the condition. Instead, it was the constantly emerging and precarious product of their efforts to communicate about intimate experiences of pain and suffering.